Contract Pharmacy Details

WALGREEN CO.
DSH110034 AU Medical Center, Inc.

Covered Entity Details

Entity Name

AU Medical Center, Inc.

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH110034

Entity Address

1120 15TH ST.
AUGUSTA, GA 30912

Medicare Provider Number

110034

Participating Start Date

12/1/1992

Last Recertification Date

8/22/2024

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA WALGREENS #15333
2493 TOBACCO RD
HEPHZIBAH, GA 30815

Pharmacy Comments

Contract Details

Approval Date

10/14/2016

Contract Begin Date

1/1/2017

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Lee Ann Liska, Chief Executive Officer
(706) 721-6569

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

10/14/2016

340B Drug Pricing Program Database